HOW TO APPLY FOR CLAIMS UNDER HEALTH INSURANCE

HOW TO APPLY FOR CLAIMS UNDER HEALTH INSURANCE POLICIES Role of an Agent

• • • Benefits under the health insurance policies Claim application forms Hospital treatment forms Availability of the forms Other attachments to the claim forms Submission of claim forms at TPA/Branch/Division.

Benefits under the health insurance policies • Hospital Cash Benefit (HCB) • Major Surgical Benefit (MSB) • Domiciliary Treatment Benefit (DTB)

• HCB and MSB available only for treatments taken in a Hospital. • Claims for HCB and MSB are processed by Third Party Administrators (TPA) • DTB claims are processed at Branch/Divisional Offices only

Claims forms • A set of Claim forms HCB/MSB consists of – Claim form-1 • To be completed by the principal insured – Hospital treatment form • To be completed by the hospital authorities where the insured has taken the treatment § One claim form set is sufficient for either HCB or MSB or Both § In case of change of hospital by the insured for treatment of the same ailment, Hospital treatment form should be submitted from each hospital where the admission has taken place, but only one claim form to be completed by the principal insured is sufficient. ( provision is made for up to 3 hospitals in a single claim form to be completed by the principal insured)

Availability of the forms • Printed forms available at the Divisional Health Units • Available in LIC Intranet website – can be printed at any branch- Jeevan Sanchar/CO depts/Health Insurance/Claims/Claim forms • Available in TPA website- available to all customers

Importance of Hospital Treatment form & other documents • The actual date and time of admission and date and time of discharge from hospital (often time is not given in the Hospital Discharge Summary) • The actual date and time of admission in ICU and date and time of discharge from ICU (often, only billing is done for ICU without giving any details of the timings) • The full details of the hospital ( to check whether the hospital is satisfying the conditions specified in the policy conditions) • The brief details of the ailment, history of illness and the course of treatment given

Importance of other documents to be attached to the claim forms • Only attested copies of the documents need to be submitted by the claimant. Originals need not be submitted. • Attestation should be by the hospital authorities or any Class I officer of LIC • The prescriptions and bills for the medicines purchased and used • The special reports if any for the test undergone during the hospitalization • Any other report/document given by the hospital on the discharge of the insured • Any other document desired by the medical team of the TPA, based on the details given in the Hospital Discharge Summary, Hospital Treatment form or other documents submitted by the claimant.

Submission of claim forms • Claim Forms should be submitted within 15 days from the date of discharge from the hospital, as per policy conditions. • Claim forms submitted within 30 days are also considered, as a special case. • Claim forms submitted after 30 days from the date of discharge are rejected for delayed submission of claims. • The claimant may appeal for condonation of delay in submission of claim forms giving the actual reason for the delay. • The Senior Divisional Manager of the Division will consider such appeals based on the merits of the case.

Submission of Claims forms • Claim forms should be sent to the TPA directly, as per policy conditions • Claim forms may also be submitted to the policy servicing Branch/Divisional Office for onward transmission to the TPA

Role of an Agent • The printed claim forms are obtained from the branch and supplied to the claimants • The correct and full details are given in the claim forms • The Hospital treatment form is completed will all the relevant data in the form • All the supporting documents are also sent along with the claim forms. • The copies of the Hospital documents are properly attested by the Hospital or by an Officer of LIC • All the pending claims are periodically verified from the Divisional Office and necessary assistance is given to the claimant in compliance

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